An 80-year-old male with severe constipation presents with massive painless abdominal distension, nausea, and failure to pass flatus. Abdominal radiography reveals a huge, dilated, inverted U-shaped loop of bowel without haustra projecting from the pelvis toward the right upper quadrant ('coffee bean sign'). What is the diagnosis and initial therapeutic procedure in the absence of peritonitis?

Answer and explanation

Correct answer: D. Sigmoid volvulus; flexible sigmoidoscopy for detorsion and decompression

  1. Step 1: Analyze radiological finding: The classic 'coffee bean sign' rising from the left lower quadrant toward the right upper quadrant is pathognomonic for sigmoid volvulus.
  2. Step 2: Determine acute management: In hemodynamically stable patients without evidence of gangrene, perforation, or peritonitis, endoscopic detorsion and decompression via flexible sigmoidoscopy is the first-line therapeutic intervention.
  3. Step 3: Note definitive plan: Elective sigmoid resection is scheduled later due to high recurrence rates (up to 50%).
Answer
Sigmoid volvulus; flexible sigmoidoscopy for detorsion and decompression.
Why not the others: Cecal volvulus presents with a comma-shaped loop in the left upper quadrant and needs surgery; appendicitis and intussusception do not produce the coffee bean sign; endoscopic detorsion is the first step only for sigmoid volvulus without peritonitis.

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